13 areas of assessment

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ESTINO, PASCUA, BUSTILLO, CORTINA

CHARLIZ RICHARD IAN , KATE
E ETHAN CHESTER

BENITEZ,
ROSELYN
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DEFINITION OF
ASSESSMENT
Assessment refers to the collection and interpretation of
clinical information. It focuses on gathering the data
about a client’s state of wellness, functional ability,
physical status, strengths and responses to actual and
potential health problems. (Gordon,1987;1994)

ASSESSMENT= OBSERVATION OF THE

PATIENT+INTERVIEW OF PATIENT AND FAMILY+
EXAMINATION OF THE PATIENT+REVIEW OF MEDICAL
RECORDS.
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PURPOSES OF
NURSING
 To gather information regarding client’s health.
ASSESSMENT
 To determine client’s normal function.
 To organize the collected information.
 To confirm hypothesis growing out of the nurse’s
interview
 To enhance investigation of nursing problems
 To frame nursing diagnosis. It increases greater
managing skills of handling patient’s problem.
 To identify the health problems. To identify client’s
strengths.
 To identify need for health teaching
 To provide data for the diagnosis phase.
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TYPES OF
ASSESSMENT
1. INITIAL ASSESSMENT: Is the assessment done within specified time after admission
to a health care agency. This assessment is done as soon as client comes to hospital
and is very comprehensive. It gathers data considering all aspects of the client’s
health.

2. FOCUS ASSESSMENT: This is a daily assessment done by nursing personnel of

admitted client. It is an ongoing process integrated with nursing care. It helps in
determining the status of specific problem identified in initial assessment.
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TYPES OF
procedures, when it is crucial toASSESSMENT
3. EMERGENCY ASSESSMENT: The emergency assessment is performed during emergency
evaluate the patient's airway, breathing and circulation, as well as
the exact cause of the problem. Emergency assessments can take place outside typical healthcare
settings and in these situations the registered nurse must also make sure that no other people are
negatively affected by the emergency rescue process. If the emergency assessment is a success
and the patient's vital signs are stabilized, the next step is usually a focused assessment.

4. TIME LAPSED ASSESSMENT: This assessment is done several months/weeks after initial
assessment. It helps in comparing the client’s current health status from the baseline data similar
to focus assessment; it also evaluates the status of problem already identified.
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THE 13 AREAS
OF
ASSESSMENT
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1.PSYCHOLOGICAL and PSYCHOSOCIAL

STATUS
The word 'psychosocial' is used in the sense of 'mental
behavior of the society as a whole'. On the other hand, the
word 'psychological' is used in the sense of 'mental
behavior'. A Psychosocial Assessment is an evaluation of
a person's mental health, social status, and functional
capacity within the community. Psychosocial
assessment generally is conducted in a question-
answer format, where a medical expert asks a
series of questions and the patient is expected to
answer them truthfully.
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EXAMPLE:
Patient Jessie Sumcad Lopez is a 48-year-old male a Roman
Catholic and born on May 28, 1973 at Sumoki, Bontoc,
Mountain Province. He is currently still living there with his wife
and children. Patient is outgoing and he is on good terms with
his wife and children. His family belongs to the middle class and
all his medical expenses are being supported by his family.
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2. MENTAL AND EMOTIONAL

STATUS
Emotional health is the ability to cope with and manage
emotions. Mental health is the ability to think clearly and
make good decisions. It's also the ability to cope with
stress and manage emotions. The mental status
examination is a structured assessment of the patient's
behavioral and cognitive functioning. It includes
descriptions of the patient's appearance and general
behavior, level of consciousness and attentiveness, motor
and speech activity, mood and affect, thought and
perception, attitude and insight, the reaction evoked in
the examiner, and, finally, higher cognitive abilities
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EXAMPLE:
Client is conscious, alert, coherent, oriented and conversant. He
is a 48-year-old male who is currently retired from his job.
Patient’s chronological age is directly proportional to his
developmental age since he speaks and acts according to his
age and maintains eye contact.
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3. ENVIRONMENTAL STATUS

Assessment involves identifying the specific

exposures to which a patient is sensitive
and locating the corresponding
contaminants in the patient's environment.
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EXAMPLE:
The patient states he is only staying in his room and is not going
out. He currently lives in a semi-concrete house with four rooms.
He shares his room with his wife. Room has 2 large windows
which resulted in good ventilation. Their house is located in a
spacious area with lots of trees. They have their water being
delivered and their toilet facility is a water-carriage type.
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4. SENSORY STATUS
The sensory exam involves evaluation of pain (or
temperature), light touch, position sense,
vibration, and discriminative sensations. This
portion of the exam is very subjective, and may
become unreliable if repeated in quick
succession. Therefore, your exam should not be
rushed, but must proceed efficiently. This
assessment involves VISUAL STATUS, AUDITORY,
OLFACTORY STATUS, GUSTATORY STATUS,
TACTILE STATUS.
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EXAMPLES:
Visual Status: Eyes are almond in shape, irises are black in color, sclera
is white, eyebrows and eyelashes are evenly distributed. His
conjunctiva is moist and pinkish. The patient states he has a blurred
vision and when light was flashed on both eyes it was reactive but
patient states, he sees stars. His eyes can follow the six cardinal
positions and eyes were able to move in full range of motion in all
directions.
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EXAMPLES:

Auditory: The patient can distinguish voices whether they are near or
far. No corrective auditory deficits and no auditory device noted being
used by the patient. Patient was also able to repeat the whispered
words on both ears when the whisper test was conducted. He
verbalized that he has no known auditory deficits nor ear infection
history and unusual sensations like ringing or buzzing
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EXAMPLES:

Olfactory status: Nose has no deviation in terms of shape and size. No

discharges were seen during the assessment. Orange peel and apple
peel were used for this test and the patient was able to differentiate
both smells from each other signifying that there are no obstructions
or abnormalities.
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EXAMPLES:

Gustatory status: His lips are dark in color and dry but symmetrical in
shape. Tongue is darkish in color and there is a presence of tooth
cavities. For this test, the patient was asked to taste a pinch of salt and
sugar with his eyes closed and he was able to correctly identify both
samples
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EXAMPLES:
Tactile status: Patient was asked to close his eyes and a cotton ball was
used to stroke on his neck, then, using another cotton ball, the student
nurse poured alcohol on it and rubbed it on the same area and he
stated that he felt a wet and cold sensation on his skin. We also
randomly introduced the sharp and dull ends of a fork and he was able
to distinguish the sharp and dull ends. He is also able to differentiate
common objects by touch such as coins and papers by doing necessary
procedures. Patient has an intact body image
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5. MOTOR STATUS
The motor exam includes evaluation of muscle
bulk, tone and strength. It also includes the
assessment of body position, coordination and
the presence of involuntary movements. You
may choose to evaluate each component in a
specific region of the body (e.g. examine all
motor functions in the arms, then legs, and then
trunk) or alternatively evaluate them
sequentially (e.g. evaluate strength in all body
regions, then evaluate tone, etc.).
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EXAMPLE:
Patient is on sitting position with slightly limited movement. He has
muscle strength of 3/5 on both upper and lower extremities, which
means that he has limited movement against gravity and some
resistance. Further, no tremors and deformities noted on both upper
and lower extremities. Upper extremities are symmetrical as well as the
lower extremities. Peripheral pulses were present such as radial. No
crepitus noted upon flexion of joints. Extremities are warm to touch.
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6.NUTRITIONAL STATUS
The state of a person's health in terms of the
nutrients in his or her diet

Nutritional assessment allows healthcare providers

to systematically assess the overall nutritional
status of patients, diagnose malnutrition, identify
underlying pathologies that lead to malnutrition,
and plan necessary interventions.
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EXAMPLE:
The patient’s skin appears to be dry; he has a good skin turgor that returns in 1-2
seconds. Hair is noted to be terminal in the scalp, eyelashes and eyebrows with no
parasite infestation. Patient has slightly dry lips and oral mucosa. The patient has
poor appetite in eating; he consumes 30% of food served. The patient has a medium
body built. Patient sees foods as a source of energy and verbalized that he has no
religious restrictions about food as well as allergies. The patient has a high protein
diet and low sodium diet, as ordered by the physician. Bowel sounds are as follows:
RUQ: 4, RLQ: 2. LUQ: 6; LLQ: 4, upon auscultation. It reveals normal bowel sounds per
minute. Abdomen is globular upon inspection and non-tender in all four quadrants
upon palpation.
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7. ELIMINATION STATUS

BOWEL ELIMINATION ASSESSMENT ( subjective

assessment of the bowel system includes asking
about the patient’s normal bowel pattern, the
date of the last bowel movement, characteristics
of the stool, and if any changes have occurred
recently in stool characteristics or pattern.)
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7. ELIMINATION STATUS

URINARY ELIMINATION ASSESSMENT

(assessment of the urinary system includes
asking questions about voiding habits,
frequency, and if there is difficult of painful
urination. The bladder may be palpated above
the symphysis pubis for distention.)
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EXAMPLE:
Patient’s frequency of urination is estimated to be 3 times per shift at
approximately 750 cc. He uses the bathroom with assistance and
privacy is observed. No pain was reported to be felt during urination.
Urinalysis revealed clear and dark yellow urine with a specific gravity
of 1.030 is used as an indicator of the kidneys ability to excrete
concentrated urine. As particle increases, so does the specific gravity.
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8. FLUID AND ELECTROLYTE STATUS

The levels of electrolytes in your body can
become too low or too high. This can happen
when the amount of water in your body
changes. The amount of water that you take in
should equal the amount you lose. If something
upsets this balance, you may have too little
water (dehydration) or too much water
(overhydration).
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EXAMPLE:

Patient is able to consume 350 cc of water. He is hooked to D5LRS 1L+

2 amps. Vit. B complex x 12 hrs., regulated at 83-84 gtts/min. He has
dry lips. He has a good skin turgor; skin and hair are slightly dry.
Patient’s skin is brownish and has pinkish nail beds. No signs of
dehydration noted as well as edema formation.
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9. CIRCULATORY STATUS

This evaluation consists of a history and

physical exam comprising inspection,
palpation, and auscultation. The history
obtained from the patient and previous
medical records reveal the presence (or
absence) of circulatory system conditions
that warrant further investigation.
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EXAMPLE:
Patient has pulse rate of 69 beats per minute and a blood
pressure of 110/70 mmHg while positions on semi fowlers. He
has normal capillary refill of 1-2 seconds. He is not cyanotic.
He has a history of cigarette smoking and alcohol drinking.
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10. RESPIRATORY
STATUS
A patient's respiratory status is how well a patient is
producing air exchange. As you would imagine,
adequate air exchange is vital to life.

A focused respiratory objective assessment includes

interpretation of vital signs; inspection of the
patient's breathing pattern, skin color, and
respiratory status; palpation to identify
abnormalities; and auscultation of lung sounds using
a stethoscope.
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EXAMPLE:

He has a respiratory rate of 20 breaths per minute. No use of

accessory muscles noted. Chest wall symmetrically expands
with each respiration and no retractions see. The patient has
history of cigarette smoking and alcohol drinking.
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11. TEMPERATURE
STATUS
Assessing body temperature is a nursing
procedure that provide a baseline data for
subsequent evaluation and nurses to
determine changes in the core temperature
of patient in response to a specific medical
intervention such giving an antipyretic drug, a
therapy and minor or invasive procedure.
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EXAMPLE:

The patient verbalized feeling of warmth and cold. His

temperature is 37.6OC, per axillary upon the initial vital signs
taking. The ward is adequately ventilated. The patient, as well,
had used only one blanket, with clothes made of cotton not
greatly affecting the client’s temperature status.
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12. INTEGUMENTARY STATUS

The assessment of the integumentary

system which includes the skin, hair and
nails is an important element of the nurse’s
assessment of the patient’s health status.
These body structures do have specific
functions but they also reflect functions or
dysfunctions of other body systems as well.
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EXAMPLE:

Patient’s skin is dry generally white, without pigmentations, no

pallor, jaundice or cyanosis. He has good skin turgor. His nail
base is soft when palpated, with capillary refill of 1-2 seconds.
His hairs are dry, evenly distributed, no parasite infestations,
and well-trimmed.
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13. COMFORT AND REST

STATUS
Comfort, rest, and sleep are needed for well-being. The
total person—the physical, emotional, social, and
spiritual—is affected by comfort, rest, and sleep
problems. Discomfort and pain can be physical or
emotional. Whatever the cause, they affect rest and
sleep. They also decrease function and quality of life.
Rest and sleep restore energy and well-being. Illness and
injury increase the need for rest and sleep. The body
needs more energy for healing and repair. And more
energy is needed for daily functions.
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EXAMPLE:

The patient sleeps experience sleep

disturbance, as reported.
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